Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania

Abstract

Background The persistence of preventable maternal and newborn deaths highlights the importance of quality of care as an essential element in coverage interventions. Moving beyond the conventional measurement of crude coverage, we estimated effective coverage of facility delivery by adjusting for facility preparedness to provide delivery services in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania. Methods The study uses data from Demographic and Health Surveys (DHS) and Service Provision Assessments (SPA) in Bangladesh (2014 DHS and 2014 SPA), Haiti (2012 DHS and 2013 SPA), Malawi (2015–16 DHS and 2013–14 SPA), Nepal (2016 DHS and 2015 SPA), Senegal (2016 DHS and 2015 SPA), and Tanzania (2015–16 DHS and 2014–15 SPA). We defined effective coverage as the mathematical product of crude coverage and quality of care. The coverage of facility delivery was measured with DHS data and quality of care was measured with facility data from SPA. We estimated effective coverage at both the regional and the national level and accounted for type of facility where delivery care was sought. Findings The findings from the six countries indicate the effective coverage ranges from 24% in Haiti to 66% in Malawi, representing substantial reductions (20% to 39%) from crude coverage rates. Although Malawi has achieved almost universal coverage of facility delivery (93%), effective coverage was only 66%.vSuch gaps between the crude coverage and the effective coverage suggest that women delivered in health facility but did not necessarily receive an adequate quality of care. In all countries except Malawi, effective coverage differed substantially among the country’s regions of the country, primarily due to regional variability in coverage. Interpretation Our findings reinforce the importance of quality of obstetric and newborn care to achieve further reduction of maternal and newborn mortality. Continued efforts are needed to increase the use of facility delivery service in countries or regions where coverage remains low.

What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal

“…Improvements in caesarean section rates were concentrated in urban areas, indicating that rising facility births did not greatly improve access to emergency obstetric and newborn care in rural areas. In line with previous studies finding substantially lower effective than crude coverage of childbirth care,18 52–54 these findings raise important concerns about the quality of care provided to women in Senegalese facilities, and elsewhere in sub-Saharan Africa.…”

“…Among sub-Saharan countries with Demographic and Health Survey (DHS) data, Senegal has the highest percentage of women delivering in facilities who report no skilled attendant (19% in 2014),9 34 and the deficit of midwives was estimated at 50% of the need in 2013 32 35. Low availability of anticonvulsants for hypertensive disorders, manual vacuum extractors and provider CEmONC training have been highlighted as gaps in EmONC readiness 36…”

“…Previous studies have highlighted low readiness to provide childbirth care in health facilities in sub-Saharan Africa, due to low provider skill and suboptimal equipment and supplies 13–21. Evidence on referral systems for transferring patients with complications between facilities in low-income countries is limited22 but indicates that these are often not functional or non-existent, with lack of communication and transport means, and poor road infrastructure 23–25.…”

Variance estimation for effective coverage measures: A simulation study

“…A 2018 literature review [5] found that of six papers that combined population and health facility data sources, four did not report an estimate of the variance of the point estimate [11,12,15,16]; one used the exact method for the product of two variables [17], and the sixth used a Taylor series expansion [19]. Recently published work on the effective coverage of childbirth defined and employed the delta method for variance calculation [23,24].…”

“…We describe three methods for constructing a 95% confidence interval around an effective coverage estimate: two analytical approaches, the exact and the delta methods, and a computer-based approach, the bootstrap method, which involves repeated sampling with parameters estimated from the observed data. The derivation for confidence interval construction using the delta method was presented previously in Wang et al [23,26].…”